Plastic surgery





The eyelids provide globe protection and preserve vision. In addition, variations in periorbital structures provide for identifiable differences in ethnicity, gender, and age and display characteristic signs of various emotional states. Reconstruction of the eyelid mandates consideration of both function and aesthetics. Anatomic considerations are vital in eyelid reconstruction, and eyelid anatomy is presented in detail in Chapter 46.


Periorbital defects can be congenital, traumatic, or ablative. Regardless of the etiology, reconstruction begins with an ophthalmologic examination and by analyzing the defect in terms of the location of the defect and the layers involved. Spinelli and Jelks divided this region into five zones—zone 1, the upper eyelid; zone 2, the lower eyelid; zone 3, the medial canthus; zone 4, the lateral canthus; and zone 5, the surrounding tissues (Figure 32.1).5 In addition, consideration is given to each layer that requires replacement. Typically, tissue grafts, local flaps, or a combination are required.

Tissue Grafts

Autologous tissue grafts are often required, either alone or in concert with a local flap. In full-thickness defects, either the anterior or posterior lamella must be reconstructed with a vascularized flap, providing a recipient site for a graft to reconstruct the other layer. An ideal donor site in anterior lamellar defects with a healthy wound bed is a full-thickness skin graft from the contralateral upper eyelid. When upper eyelid skin is limited, the retroauricular region or the supraclavicular region offers a secondary source. Fascia grafts, either from the deep temporal fascia or the tensor fascia lata, can be used to provide structural integrity for the eyelid or canthal regions. These can act as spacer grafts or can play a role in procedures for the treatment of upper eyelid ptosis. Cartilage grafts are typically used as a spacer or to replace the missing tarsal plate. Ear cartilage from the scapha most resembles the native tarsal plate, but thinned conchal grafts are a reasonable alternative. Nasal chondromucosa provides both a structural layer and the mucous membrane but has more potential donor site problems and is used infrequently. Resurfacing defects of the posterior lamella can only be accomplished with a tarsoconjunctival graft. Donor tissue is limited, however, and buccal or hard palate mucosal grafts are better options.2

FIGURE 32.1. Periorbital zones as described by Spinelli and Jelks.5


Periorbital reconstruction by zone is summarized in Figure 32.2.

Zone 1: Upper Eyelid Reconstruction

Proper repair of the upper eyelid is necessary for globe protection. Partial-thickness defects of the anterior lamallae are divided by size into those that are less than or greater than 50% of the horizontal lid dimension. For defects that are less than 50% of the lid, local tissue advancement and primary closure are performed. For defects larger than 50% of the lid length, a full-thickness skin graft is typically required.5 Incisions should be made in the natural lid crease if possible.

Treatment of full-thickness defects is also based on defect size. For defects of less than 25%, primary closure by converting the defect into a pentagonal shape can help avoid deformity.5 In youth, there is less eyelid laxity, and primary closure may not be possible in wounds greater than 20%. In elderly patients, whose lids have more laxity, defects up to 30% of the horizontal lid dimension may be closed primarily but may require a lateral canthotomy for a tension-free repair.2 Care should be taken to precisely approximate the lid margin. A layered closure is performed with attention to the alignment of the tarsal plates.

For defects greater than 25% but less than 75% of lid length, there are a number of reconstructive options. Most of these require a vascularized regional flap, which provides a recipient bed for a graft to separately reconstruct the anterior or posterior lamella. A sliding tarsoconjunctival flap borrows tissue from the uninjured portion of the ipsilateral upper eyelid. This flap is an option for posterior lamella defects involving the medial or lateral aspect of the upper eyelid. The inferior incision for this horizontally based flap is 4 mm above the lid margin and extends to create a flap that is equal to the defect size. The superior incision is designed to fit the defect, and a vertical relaxing incision is required in the tarsal plate to allow for advancement.2 A full-thickness skin graft is required for coverage of this flap to reconstruct the anterior lamella. In central wounds, a tarsoconjunctival flap can be developed from the lower eyelid as is done for lower eyelid reconstruction in the Hughes procedure.6 (See section “Zone 2: Lower Eyelid Reconstruction.”) This approach has the obvious disadvantage of a second procedure and obstruction of vision for the period prior to flap division.

The Cutler-Beard bridge flap is a full-thickness composite flap from the lower eyelid.7 A transverse full-thickness incision is made approximately 5 mm inferior to the lid margin in the lower eyelid, which allows flap elevation without compromising vascularity to the remaining lower eyelid. The horizontal width of the flap should match the width of the upper eyelid defect, and vertical full-thickness incisions are made to the inferior fornix at this width. The flap is advanced posterior to the remaining lid margin and secured into the upper eyelid defect with a multilayer closure. The conjunctiva can be separated from the musculocutaneous flap, and a cartilage graft can be placed for added support as this flap typically has little or no tarsus within it.2 The flap is divided at approximately 6 weeks with 2 mm excess vertical height. This allows for the removal of 1 to 2 mm of musculocutaneous tissue and anterior rotation of a conjunctival flap, which in turn provides a lid margin with a mucous membrane lining instead of keratinized epithelium. The lower eyelid often requires revision. The disadvantages of this repair include (1) a two-stage reconstruction with obstructed vision between stages, (2) disturbance to the lower eyelid that may require future revision and/or lid-tightening procedures, and (3) lack of lashes in the reconstructed segment.

FIGURE 32.2. Reconstructive algorithm based on reconstructive zones.

The Tenzel semicircular flap is a regional flap that provides tissue for both the anterior and posterior lamellae.8 A superiorly based semicircular flap of up to 6 cm in diameter is designed and advanced medially. A canthotomy is required; and once advanced, the flap must be secured to the lateral orbital wall to provide support and help recreate the natural convexity of the upper eyelid. The conjunctiva is also undermined and advanced to provide the lining of the flap. This flap is ideally suited for those defects that encompass 40% to 60% of the upper eyelid.2

For large defects (those greater than 75%), the Mustarde lower lid switch flap is an option.9 A large full-thickness portion of the lower eyelid is rotated based on the marginal vessels to fill the upper eyelid defect. This flap is typically delayed up to 6 weeks before pedicle division and inset. This flap provides a composite reconstruction of the upper eyelid and, therefore, the possibility for adequate protection of the globe. The disadvantage is that it sacrifices a significant portion of the lower eyelid that must then be reconstructed with cheek advancement and posterior lamella grafts.

Other options for large upper eyelid defects that involve other surrounding zones include a forehead flap, a Fricke flap, or a glabellar flap (see section “Zone 3: Medial Canthal Reconstruction”). The Fricke flap borrows lower forehead tissue as a laterally based unipedicled flap, which can be transposed to reconstruct either an upper or lower eyelid defect.

Zone 2: Lower Eyelid Reconstruction

Lower eyelid defects are more common than defects in other zones because of the higher incidence of lower eyelid skin cancer (Chapter 14). The lower eyelid is anatomically analogous to the upper eyelid, that is, where the capsulopalpebral fascia is homologous to the levator aponeurosis and the inferior tarsal muscle is homologous to Mueller’s muscle. The main difference is that the lower eyelid is shorter and the tarsal plate is 4 mm in vertical height compared with 10 mm in the upper eyelid. Although lower eyelid position is extremely important in protecting the globe and preventing dryness, it plays a relatively passive role when compared with the upper lid.

Reconstruction of the lower eyelid can be approached algorithmically. Similar to the upper eyelid, lower eyelid defects are treated based on size and on which layer is missing. For superficial defects involving up to 20% of lower lid length, primary closure is usually possible in older patients; younger eyelids have less laxity. As the wound approaches 50%, closure with local tissue advancement is required and, in many cases, a lateral canthotomy is required. A tension-free repair is necessary or lid malposition will result. There are aesthetic benefits to using the normal lid margin when local tissue advancement is utilized in comparison to reconstructive options that reconstruct the lid margin with other tissues.

For superficial defects greater than 50% of lid length with a healthy wound bed, a full-thickness skin graft is a good option. Alternative options are local myocutaneous flaps, including the unipedicled Fricke flap and the bipedicled Tripier flap. The Tripier flap is a bipedicled flap from the upper eyelid transposed to reconstruct lower eyelid defects. This flap includes preseptal orbicularis oculi muscle. The Fricke flap is similar but is a unipedicled flap and is adequate for defects that extend to the mid-lower eyelid or just beyond. The bipedicled option is better utilized in larger defects. Both flaps incorporate more soft tissue than a full-thickness skin graft and, thus, provide for a thicker reconstruction that may require revisional debulking.

Small full-thickness lower lid defects are closed primarily. Care is taken to align and repair the tarsal plate. As in partial-thickness defects, a lateral inferior cantholysis may be required to prevent tension. To avoid dog-ear formation at the inferior aspect of the closure, the incision should be slanted laterally or a Burow’s triangle can be removed.

Once defects are greater than a few millimeters, they are best divided into those that involve <50% of the lower eyelid, 50% to 75% of the lower eyelid, and >75% of the lower eyelid. Full-thickness defects that are 50% or less of the lower eyelid can be approached with the inferiorly based Tenzel semicircular flap.8 The semicircular incision extends superiorly and laterally with a diameter of 3 to 6 cm depending on the defect size and tissue laxity. Dissection is in a submuscular plane, and the inferior ramus of the lateral canthal tendon is divided to allow medial rotational advancement. In larger defects, there may be a paucity of support laterally since the tarsus is advanced medially. In these cases, the flap can be supplemented with a laterally based periosteal flap, conchal cartilage, or septal cartilage. The flap can also be supported with sutures to the lateral orbital periosteum.

For defects larger than 50%, the anterior and posterior lamellae are typically reconstructed separately. For lateral full-thickness defects involving 50 to 75% of the lower eyelid margin, the posterior lamella can be addressed with the Hewes procedure.10 A laterally based upper eyelid tarsoconjunctival flap is pedicled on the superior tarsal artery and transposed to the lower eyelid. The anterior lamella can then be reconstructed with a skin graft or a second upper eyelid flap such as the Tripier flap. When defects of this size are centrally located, the Hewes procedure may not provide enough length for transposition; and a tarsoconjunctival graft is an alternative option. When the posterior lamella is reconstructed with a nonvascularized graft, the anterior lamella must incorporate well-vascularized tissue. Options include a myocutaneous flap from the upper eyelid or vertical myocutaneous flap from the lower eyelid and cheek.2 The vertically based myocutaneous flap is developed just as a skin muscle flap is elevated in a lower blepharoplasty. On vertical advancement, triangles of redundant tissue are removed.

An alternative method for reconstruction of the posterior lamella is the Hughes tarsoconjunctival flap procedure6 from the upper lid which is best for defects greater than 50%, including total lower eyelid reconstructions. The flap is developed starting 4 mm above the upper eyelid margin to avoid compromising upper eyelid integrity and consists of a segment of tarsus and conjunctiva. The width is designed to match the missing posterior lamella segment of the lower eyelid and advanced into the lower eyelid defect. The advanced tarsal segment is secured to the remaining lower eyelid tarsal borders, canthal tendons, or periosteum depending on what remains. This vascularized flap is then covered with a full-thickness skin graft or a myocutaneous flap obscuring vision for several weeks. Separation of the Hughes flap can be performed at 3 to 6 weeks. At this stage, care is taken to allow both Muller’s muscle and the levator to retract to their native positions to preserve upper eyelid function. In addition, in the lower eyelid the conjunctiva is rolled over the recreated lid margin to prevent irritation from corneal contact with keratinized skin.

The alternative for defects greater than 75% is the Mustarde flap.11 The traditional Mustarde approach includes a large rotational cheek flap advanced to reconstruct the anterior lamella and a nasal chondromucosal graft to reconstruct the posterior lamella. As highlighted earlier, alternatives are available for posterior lamella grafts. The flap is designed to extend superiorly toward the brow so that closure will result in upward tension on the lower lid. Once elevated and advanced, the flap is secured either to the medial canthus or to medial orbital periosteum. The flap is sutured to the periosteum laterally at a point above the lateral canthus.

Zone 3: Medial Canthal Reconstruction

The medial canthal region is anatomically complex and requires attention to the lacrimal system. When defects of both the upper and lower eyelids encroach on the medial canthus, one must address the canalicular system via intubation with a silicone tube. Once the lacrimal system is protected, attention is directed to the supporting structures of the medial canthus. If the medial retinaculum is detached from the bone, it must be reattached via the posterior reflection on the lacrimal crest posterior to the lacrimal sac. This location of fixation serves the dual function of avoiding damage to the lacrimal system and maintaining the natural curve of the lower eyelid directly apposed to the globe. When a medial canthal tendon deficiency is present, a fascial graft can be incorporated into the repair. Methods for fixation include sutures to the periosteum, drill hole fixation, bone anchors, and in cases of bone deficiency, transnasal wires or to a gap spanning plate.

The skin defect is addressed in a number of ways. In the appropriately selected patient, healing by secondary intention is an acceptable method in the medial canthus. This method may result in epiphora, epicanthal folds, and medial ectropion. As in other periorbital defects, a full-thickness skin graft is also a valid option, but contraction may yield an unsightly result. A medially based upper eyelid myocutaneous flap, based on the infratrochlear vessels, can be rotated to cover relatively small defects. Unique to the medial canthus is the glabellar flap, which is a modified rhomboid flap or a V-Y flap that provides for immediate closure of large medial canthal defects.5 Cutaneous coverage in this region by any method frequently results in cicatricial epicanthal folds requiring revision.

Zone 4: Lateral Canthal Reconstruction

The crucial element of zone 4 is the fixation provided by the lateral canthal tendon, which almost always requires attention in zone 4 reconstructions and a large number of other periorbital reconstructions. When the tendon is present but lax, a simple canthopexy is performed. When the lateral canthus is disrupted but present, a canthoplasty is performed. In both situations, the goal is to overcorrect the tissue laxity as recurrent laxity is expected.5

When no lateral canthus remains, alternative reconstructive methods must be employed. If sufficient upper and lower tarsal plates are present, then lateral advancement is possible. The tarsal plates can be secured to the lateral orbital periosteum at the level of Whitnall’s tubercle. If needed, a tarsal strip can be fashioned to help with lateral fixation (see section “Lower Eyelid Malposition”). If no orbital periosteum is present, then drill holes are made; and in situations of bone deficiency, a bone spanning plate is used.2,5 If there is no preexisting eyelid laxity, then a tarsal strip may not be sufficient; in these situations, crossing periosteal flaps can be elevated from the lateral orbital rim. When larger defects of the upper or lower eyelid tarsal plates are present, then the reconstructive technique utilized for posterior lamella reconstruction is incorporated into the lateral canthal reconstruction.

The skin defect is approached either with a local flap or a full-thickness skin graft. Local flap options include an inferiorly based cheek flap, two small semicircular flaps, or a superiorly based rotational flap. Rhomboid transposition flaps can also be used. The goal is to create an acute angle with a lateral canthus slightly higher than its corresponding medial canthus (Chapter 46).

Zone 5: Periocular Defects Reconstruction

Zone 5 defects include the periocular areas that are contiguous with zones 1 through 4. Often a zone 5 defect occurs in conjunction with defects in other zones, and, in these situations, the principles discussed above are modified to allow reconstruction from the remaining available tissue. When an isolated zone 5 defect occurs, the other zones are often still affected. For instance, cheek reconstruction will often result in lower lid malposition, even if the lower lid is normal if insufficient attention is paid to lower lid and/or canthal support.


Complications occur more commonly in large reconstructions, specifically when the defect is greater than 50% in zone 1 or 2 and when the defect is greater than 4 cm in zones 3, 4, and 5. All medial canthal reconstructions are fraught with higher complication rates. Inadequate lateral canthal support also results in higher complication rates.5 Early complications include corneal abrasion, chemosis (which can often be limited by a Frost stitch or temporary tarsorrhaphy), hematoma, and/or flap/graft failure. Late complications include corneal exposure, canthal laxity, lid malposition, abnormal lacrimal drainage, and an unsatisfactory cosmetic result.


Periorbital anatomy is a critical component of appearance. Therefore, a thorough understanding of secondary procedures to optimize the aesthetic outcome is paramount. Contour defects often occur following periorbital reconstruction. These defects can be related to fat atrophy and/or adhesions between the various layers. As in other areas, fat grafting is a validated periorbital adjunctive procedure (Chapter 44).

In both the medial and lateral canthal zones, epicanthal folds can develop following reconstructive efforts. These are addressed with a single Z-plasty, double Z-plasties, or a Mustarde “jumping man” flap.12 In addition, a larger transposition Z-plasty and canthal tendon repositioning are required for vertical displacement of either the medial or lateral canthus.


Lower eyelid position is dictated by the balance of intrinsic and extrinsic forces. When in equilibrium, the lower eyelid is positioned approximately 1 mm above the lower limbus firmly in contact with the globe. Imbalance in these forces results in lower lid malposition, producing scleral show and potentially ectropion (eversion of the lid) or entropion (inversion of the lid). Age produces involutional changes, and scarring from trauma or surgical intervention produces cicatricial changes, both of which affect the balance of forces resulting in lid malposition.

Age-related instability in the lower eyelid is caused by progressive laxity in the tarsoligamentous sling. Ectropion may result from orbicularis oculi atrophy, and entropion may result from orbicularis oculi hypertrophy. The approach is similar between the two conditions with the focus on tightening of the tarsoligamentous sling with various types of canthopexy or canthoplasty. In contrast, cicatricial ectropion or entropion is typically caused by scarring in one of the lower eyelid layers resulting in a tissue deficiency and is treated by tissue replacement.2

Preoperative Evaluation

As in all periorbital procedures, a standard eye examination is important. Specific to lower lid malposition, evaluation focuses on the important regional anatomy, including the canthal position, the lower lid position, the extent of eversion or inversion, anterior distraction and snap tests to asses tone and laxity, and the malar support. The snap test is performed by pulling the lower eyelid down and away from the globe, holding it there for a few seconds, and grading its propensity to return to the initial position. A normal lid returns to a normal anatomic position immediately, and an abnormal examination is any deviation away from this. The relationship between malar support and the globe has been described by Jelks in terms of a positive or negative vector and is discussed in terms of cosmetic surgery in Chapter 46. If the cornea projects past the inferior orbital rim, then a negative vector exists. A negative vector is a known risk factor for lower eyelid malposition in periorbital surgery.13 The adequacy of globe lubrication via tear production is evaluated with the Schirmer test and the tear film breakup test. In addition, any signs of corneal irritation are documented.1,3

Surgical Approaches

Lower eyelid malposition can be addressed with a number of corrective procedures.14 A procedure addressing the lateral canthus is always required. Cases of cicatricial abnormality require addition of tissue and cases of lid laxity require removal of the tissue. In cicatricial ectropion, the anterior lamella can be reconstructed with a skin graft or local flap as described in the eyelid reconstruction section. In cicatricial entropion, the posterior lamella can be reconstructed with a palatal mucosal graft. There are also complex forms of ectropion and entropion involving multiple layers that require a combination of procedures including a cartilage spacer graft.2

Canthopexy. In a standard canthopexy (Figure 32.3), the canthal tendon is not divided or shortened but is resecured in a new position. Only mild lower lid laxity can be treated in this fashion. Canthopexy is attractive because it involves minimal tissue disruption, can be performed from either a transcutaneous or transconjunctival approach, is relatively easy to perform, and does not risk deforming the normal acute angle of the lateral canthal region like the canthoplasty.

FIGURE 32.3. Canthopexy. The canthopexy is a common procedure used in adjunct to other periorbital procedures. Reproduced from Spinelli HM. Eyelid malpositions. In: Spinelli HM, ed. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Elsevier; 2004:47, with permission.

Canthoplasty. Canthoplasty involves division of the lateral canthus with reconstitution and repositioning and is more complex and versatile than canthopexy. When repositioning the canthal tendon, it should be reinserted on the inside of the lateral orbital rim to maintain lower eyelid contact with the globe. As mentioned in Chapter 46, the more prominent the globe, the higher the canthus is placed. The canthoplasty can be combined with a lid-shortening procedure for laxity. The degree of lower lid excision is determined by pulling the lower eyelid laterally to the lateral orbital rim. The new tarsal border is then secured inside the lateral orbital rim. In some situations, specifically in cases of involutional entropion, redraping of the orbicularis oculi muscle is important for successful correction.2

Tarsal Strip Canthoplasty. The tarsal strip canthoplasty (Figure 32.4) is similar in design to the combined procedures described above but incorporates a canthoplasty with a lid-shortening procedure. The redundant lower eyelid tissue is not completely excised but instead a strip of tarsus is denuded of skin and is used to recreate the inferior component of the lateral canthal tendon. An approximately 3 mm wide segment of tarsus (depending on shortening required) is circumferentially stripped of all tissues, including the skin, lashes, conjunctiva, and capsulopalpebral attachments. This strip is then advanced and secured inside the lateral orbital rim. Redundant superficial tissue is excised, and care is taken to appropriately align the gray line of the upper and lower eyelids. This validated powerful tool has produced long-term satisfactory results, but has the potential disadvantages of distorting the punctual position of the inner canthus and creating a discrepancy between the upper and lower eyelids.2,14

FIGURE 32.4. The lateral tarsal strip procedure provides for a great deal of versatility in repositioning the lateral canthus. Reproduced from Spinelli HM. Eyelid malpositions. In: Spinelli HM, ed. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Elsevier; 2004:39, with permission.


Blepharoptosis, or ptosis, is an upper eyelid malposition in which the upper eyelid falls below its normal level of 1 to 2 mm below the upper limbus. Upper eyelid ptosis is caused by a number of anatomic problems involving the levator palpebrae superioris muscle or its aponeurosis and/or Muller’s muscle. In addition to recognition of the anatomic problem, the etiology is relevant. Ptosis can be congenital or acquired. Congenital cases have poor levator function.

Evaluation and Examination

Initial examination is focused on the levator palpebrae superioris muscle and the levator aponeurosis. The levator function, or excursion, is measured by immobilizing the brow and monitoring the upper eyelid movement from downward gaze to upward gaze. The difference between levels of the upper lid margin in each position is recorded. Normal excursion is 12 mm with an acceptable range of 10 to 15 mm. Fair function is 6 to 9 mm and poor function is 5 mm or less.

Levator dehiscence is typically from a thinning and stretching of the levator aponeurosis, allowing dehiscence from the tarsal plate and ptosis. In many cases, the connections to the dermis are not attenuated, which results in an increasingly elevated supratarsal fold as the ptosis worsens. Levator dehiscence is an acquired involutional problem in older adults but can occur in trauma as well.

As in the other areas of periorbital surgery, standard ophthalmologic examination is important. Specific to the upper eyelid ptosis, important clinical information includes a standard history to elicit systemic disorders that could cause eyelid ptosis. There should be a low threshold for a formal neurological examination, especially when there are other signs of a neuromuscular process, such as myasthenia gravis. Regionally, pseudoptosis can present as an inferiorly displaced upper eyelid that is not actually related to the eyelid retractors but instead to a separate orbital issue. This is seen in enophthalmos, brow ptosis, orbital tumors, and dermatochalasia.

The goal of ptosis surgery is to restore the upper eyelid to its correct position while creating as little lid stiffness and lagophthalmos as possible. In an effort to avoid compromising protection of vision, a preoperative examination should verify an intact Bell’s phenomenon and the protective capacity of both eyelids.


The surgical approach to ptosis typically involves levator manipulation (Table 32.1). Regardless of the chosen procedure, some technical points are worth emphasizing. Epinephrine can stimulate Muller’s muscle and produce a 1 to 2 mm elevation of the upper lid and must be accounted for during final eyelid adjustments. When assessing upper eyelid position, the lights should be dimmed as bright lights cause squinting. If available, transparent corneal shields are used to allow for visualization of the pupil.

Levator Repair or Resection with Advancement. The levator repair or advancement procedure is the versatile procedure used for upper eyelid ptosis and is applicable to a wide range of severity. As long as greater than 5 mm of levator excursion exists, this procedure is an option. A standard upper blepharoplasty incision is used, allowing for concurrent removal of redundant skin and orbicularis oculi muscle. The septum is opened and preaponeurotic fat is retracted exposing the levator aponeurosis. If intact, the aponeurosis is incised near the tarsal border; and the levator is elevated off of Muller’s muscle. The levator is advanced over the tarsal border to simulate the levator advancement. In general, 1 mm of levator advancement gives a 1 mm correction of ptosis, but results vary based on the degree of levator function and can be difficult to standardize. An awake patient can cooperate to help guide the appropriate amount of advancement. If this technique is utilized, a temporary suture is placed at the presumed level of advancement, the patient is repositioned to a sitting position, the overhead lights are pointed away from the patient, and the patient is asked to look up and down. Once the appropriate advancement is determined, the aponeurosis is secured to the tarsal border and excess is excised.3 An alternative technique involves placement of a double-arm suture 2 to 3 mm below the superior border of the tarsal plate at the pupil midline brought out at the musculoaponeurotic junction. A surgeon knot is then tightened until the upper and lower eyelids are gapped; and a spring back test, similar to that utilized for evaluating lower eyelid laxity, is employed to set final tension.2

A levator plication can alternatively be performed with a similar approach. In this technique, the levator aponeurosis is exposed but not divided or elevated and vertical plication sutures are placed to tighten the levator aponeurosis. It requires less dissection than the levator advancement but can result in a bulge from redundant tissue.

Tarsoconjunctival Mullerectomy (Fasanella-Servat Procedure). In situations of mild ptosis with good levator excursion, the tarsoconjunctival Mullerectomy is an option (Figure 32.5).15 This procedure involves a posterior approach in which the upper eyelid is everted and hemostatic clamps are used to grasp the conjunctiva, tarsus, and Muller’s muscle at the tarsal muscular junction. The clamps are positioned in a symmetrical fashion and follow the normal curve of the lid. A running horizontal mattress suture of nonabsorbable monofilament is then placed under the clamp with its ends exiting through the anterior skin. The suture is secured, clamped tissue is sharply resected, and the clamps are removed. The conjunctiva is smoothed, and the eyelid is reduced. The suture must be placed in a manner so that it can be pulled out at approximately 1 to 2 weeks. This procedure has the disadvantage of limited flexibility and inability to adjust the amount of ptosis correction. In addition, with the posterior approach and resection of the conjunctival surface there is increased risk of corneal abrasion.3

FIGURE 32.5. The tarsoconjunctival mullerectomy (Fasanella-Servat procedure). Reproduced from Spinelli HM. Eyelid malpositions. In: Spinelli HM, ed. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Elsevier; 2004:100, with permission.

FIGURE 32.6. Frontalis sling. A. The single strand repair and (B) the double strand repair.

Frontalis Sling. The frontalis sling is employed in situations of poor or absent levator function. In this procedure, the upper eyelid is tethered to the frontalis muscle such that upper eyelid elevation relies on brow elevation. Despite inadequate levator function, the eyelid must have good excursion on passive movement for this procedure to be successful. The main variations in this procedure revolve around the type of suspensory material (either autologous or alloplastic) and the configuration of the suspension. The standard autologous options are tenser fascia lata and palmaris longus tendon, and the alloplastic material commonly used is silicone. Autologous reconstruction has advantages, but alloplastic material is a good choice in the very young patient that does not have sufficient donor material or when concerns exist for globe protection that may require procedure reversal. The popular configurations are a two-strand repair with double triangular and rhomboid design or a single-strand repair with a single rhomboid design. Either multiple stab wounds or an eyelid crease incision is used to expose the tarsal plate. The material of choice is then tunneled in a submuscular plane toward the brow. In the single-strand method the lateral arm is passed to a point midway between the lateral limbus and the canthus and the medial arm is passed to a similar position medially. The lateral vector should be slightly stronger and, therefore, the lateral arm is tunneled to a slightly higher position than the medial arm (Figure 32.6A). The double-strand configuration involves four points of fixation to the tarsal plate and three points of fixation in the brow (Figure 32.6B). At a final point, the suspensory material is secured to the brow and the tarsal border. The brow is then elevated to simulate the function of frontalis and gauge the ptosis correction. Lagophthalmos is a common problem following the frontalis sling, especially in the immediate postoperative time period.


Complications following ptosis repair include wound dehiscence, hematoma, infection, asymmetry (overcorrection or undercorrection), entropion, ectropion, and corneal irritation or injury. The most common of these is asymmetry from undercorrection, which often requires operative revision. In cases of overcorrection, lagophthalmos results in dry eye and corneal irritation. This can be treated temporarily with a tarsorrhaphy suture and lubrication but will require operative revision if persistent. Asymmetry of the lid crease can occur if it is not appropriately reapproximated at the time of closure. Surgical correction of unilateral ptosis can result in postoperative contralateral ptosis if subclinical ptosis is not recognized preoperatively. See Chapter 46 for a discussion of Herring’s law.

Suggested Readings

1.  Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004.

2.  McCord CD, Codner MA. Eyelid and Periorbital Surgery. St. Louis, MO: Quality Medical Publishing, Inc.; 2008.

3.  Newman MI, Spinelli HM. Reconstruction of the Eyelids, Correction of the Ptosis, and Canthoplasty. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

4.  Zide BM. Surgical Anatomy Around the Orbit: The Systems of Zones. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

5.  Spinelli HM, Jelks GW. Periocular reconstruction: a systematic approach. Plast Reconstr Surg. 1993;91:1017-1024; discussion 1025-1016.

6.  Hughes W. Reconstruction of the lids. Am J Ophthalmol. 1945;28:1203.

7.  Cutler NL, Beard C. A method for partial and total upper lid reconstruction. Am J Ophthalmol. 1955;39:1-7.

8.  Tenzel RR. Reconstruction of the central one half of an eyelid. Arch Ophthalmol. 1975;93:125-126.

9.  Mustardé JC. Eyelid reconstruction. NORB. 1982;1:33-43.

10.  Hewes EH, Sullivan JH, Beard C. Lower eyelid reconstruction by tarsal transposition. Am J Ophthalmol. 1976;81:512-514.

11.  Mustarde JC. Reconstruction of Eyelids. Ann Plast Surg. 1983;2:1-21.

12.  Mustardé JC. Epicanthus, telecanthus, blpeharophimosis and hypertelorism. In: Mustardé JC, ed. Repair and Reconstruction in the Orbital Region. Edinburgh: Churchill-Livingstone; 1980:332-363.

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